Case of the Week

Editor: Mahmut Akgul (akgulm@amc.edu)

2022-31/August 1

Contributors: Delyane de Azevedo Batista Santiago, Daniel Athanazio

Bilateral orchiectomy was performed in an elderly male with prostatic adenocarcinoma with bone metastasis. (First 3 images are from the left testis, whereas the last 2 images are from the right testis).

Click on the below thumbnails to enlarge photos.

Quiz

1. What is the correct diagnosis?

a) Adenomatoid tumor

b) Large cell calcifying Sertoli cell tumor

c) Intratubular large cell calcifying Sertoli cell tumor

d) Intratubular yolk sac tumor and fibrosis scar with calcification

e) Intratubular prostatic adenocarcinoma and calcified eggs of Schistosoma mansoni

The left testis showed an incidental finding of a few seminiferous tubules involved by a papillary epithelial lesion that showed PSA expression at immunohistochemistry. Both orchiectomy specimens were totally embedded for histology analysis and no more than two or three sectioned tubules were observed with this lesion. The photomicrograph of the PSA immunostain shows an isolated small gland suspicious for intertubular (invasive) pattern of growth. There was also no intraepithelial lesion in epididymis or rete testis. An intratubular pattern of prostatic adenocarcinoma to the testis has been long known (Bradham 1951, Kay et al. 1954, Thon et al. 1985, Bonfim et al. 2019) but rarely reported. Such dissemination in the absence of invasive parenchymal lesions have been attributed to tumor retrograde spread through the vas deferens.

The larger study to date on this issue was the case series of Ulbright and colleagues (2008) of metastatic tumors to the testis. Among 11 cases of non-incidental metastasis, three showed prominent involvement of tubular system – and two of them without any evidence of invasive disease. Most reported cases of intratubular spread shows a cribriform (high-grade) pattern of growth. This case showed a papillary and micropapillary lesion strikingly reminiscent of a high-grade prostatic intraepithelial neoplasia.

It is worthy pointing out that a recent report by Arnesen and colleagues described expression of other markers of prostatic differentiation in neoplastic and normal testis. NKX3.1 diffusely and strongly stains Sertoli cells, Sertoli cell nodules and is expressed in 2/22 tested sex-cord tumors of the testis and ovary (including one large cell calcifying Sertoli cell tumor). Prostein (P501S) was commonly expressed in normal Leydig cells, in Sertoli-Leydig cell tumors of the ovary (9/12), and Leydig cell tumors (2/3).

The right testis had no neoplastic lesion but showed a massive interstitial accumulation of calcified eggs of Schistosoma mansoni. Note the characteristic lateral spike of these eggs. No eggs were detected in the left testis. Such asymmetric distribution of eggs may reflect the availability of portosystemic anastomoses (Lopes et al. 2007; Athanazio and Athanazio 2008). Egg deposition in testicular tissue may not require any anatomical variation since the posterior vein to the spermatic chord (cremasteric vein) drains into epigastric veins. This determining factor for egg load may indeed define which patients may develop large lesions that may clinically present as testicular nodules.

Arnesen C, Eich ML, Pena MDCR, Cappel JR, Schwartz L, Rais-Bahrami S, Faraj SF, Prieto Granada C, Gordetsky JB. NKX3.1 and Prostein Expression in Testicular Tissue and Sex Cord-stromal Tumors. Am J Surg Pathol. 2020 Jan;44(1):61-67.

Athanazio DA, Athanazio PR. Asymetric testicular schistosomal infection. Braz J Infect Dis. 2008;12(6):461.

Bomfim LR, Lara RC, Guimarães LC, Santos CC. Braga SQP, Monti PR. [Carcinoma de próstata com metástase testicular – relato de caso]. Urominas 2019: vol. 6 (5). http://urominas.com/carcinoma-de-prostata-com-metastase-testicular-relato-de-caso/

Bradham AC. Prostatic carcinoma with metastasis to the testicle. J Urol. 1951;66:122–126.

Janssen S, Bernhards J, Anastasiadis AG, Bruns F. Solitary testicular metastasis from prostate cancer: a rare case of isolated recurrence after radical prostatectomy. Anticancer Res. 2010; 30(5):1747-9.

Kay S, Hennigar GR, Hooper JW Jr. Carcinoma of the testes meta- static from carcinoma of the prostate. Arch Pathol. 1954;57:121–129.

Lopes R.I., Leite K.R., Prando D., Lopes R.N. Testicular schistosomiasis caused by Schistosoma mansoni: a case report from Brazil. Brazilian Journal of Infectious Diseases 2007;11:523-4.

Thon W, Mohr W, Altwein JE. Hoden- und Nebenhodenmetastase eines Prosattakarzinoms. Urologe [A]. 1985;24:287–290.

Ulbright TM, Young RH. Metastatic carcinoma to the testis: a clinicopathologic analysis of 26 nonincidental cases with emphasis on deceptive features. Am J Surg Pathol. 2008 Nov;32(11):1683-93.

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